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Aims This study aimed to explore ocular and systemic factors associated with pathologic myopia in patients with high myopia and develop predictive models for differentiating between simple high myopia and pathologic myopia, particularly in its early stage.Methods This cross-sectional study was conducted on 2767 patients with bilateral high myopia at baseline follow-up. Demographic, ocular biometric and clinical data were collected, including age, corrected distance visual acuity, axial length (AL), spherical equivalent (SE), myopic atrophy maculopathy (MAM) grading based on the International Meta-Analysis for Pathologic Myopia criteria and ocular and systemic comorbidities. Multimodal imaging techniques were employed to assess plus lesions and posterior staphyloma. Logistic regression was used to identify associated factors and develop predictive models.Results Among all patients, 1697 (61.33%) were classified as having pathologic myopia. Its prevalence increased with longer AL and more severe SE. Significant ocular comorbid associated factors included cataract, epiretinal membrane, foveoschisis, full-thickness macular hole, retinal detachment and strabismus, and hypertension was the only systemic associated factor identified. Predictive models for differentiating simple high myopia and pathologic myopia, MAM categories 1 and 2, achieved area under the curve values up to 0.978 and 0.964, respectively.Conclusion This study underscores the high prevalence of pathologic myopia in a highly myopic population and identifies ocular and systemic associated factors for pathologic myopia. The developed predictive models provide valuable tools for distinguishing between simple high myopia and pathologic myopia, facilitating early diagnosis and management.